Provider Demographics
NPI:1104867456
Name:OFFUTT, MATTHEW L (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:OFFUTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PARKWAY 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4900
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:4423 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-3235
Practice Address - Country:US
Practice Address - Phone:502-495-2400
Practice Address - Fax:502-499-3606
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY34028207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64033400Medicaid
KYH46917Medicare UPIN
KY64033400Medicaid
KYP00301256Medicare PIN